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Safety Recommendation Details

Safety Recommendation A-84-123
Details
Synopsis: ON FEBRUARY 28, 1984, SCANDINAVIAN AIRLINES SYSTEM (SAS) FLIGHT 901, A MCDONNELL DOUGLAS DC-10-30 OF NORWEGIAN REGISTRY, WAS A REGULARLY SCHEDULED INTERNATIONAL PASSENGER FLIGHT FROM STOCKHOLM, SWEDEN, TO JOHN F. KENNEDY INTERNATIONAL AIRPORT (JFK), NEW YORK, WITH AN EN ROUTE STOP AT OSLO, NORWAY. FOLLOWING A CATEGORY II INSTRUMENT LANDING SYSTEM (ILS) APPROACH TO RUNWAY 4 RIGHT AT JFK, THE AIRPLANE TOUCHED DOWN LONG AND FAST AFTER WHICH IT ROLLED OFF THE END OF THE RUNWAY AND CAME TO REST WITH ITS NOSE PARTIALLY SUBMERGED IN A TIDAL WATERWAY ABOUT 600 FEET BEYOND THE DEPARTURE END OF THE RUNWAY. ALL OF THE 163 PASSENGERS AND 14 CREWMEMBERS EVACUATED THE AIRPLANE SAFELY, BUT WITH SOME INJURIES.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: APPLY THE FINDINGS OF BEHAVIORAL RESEARCH PROGRAMS AND ACCIDENT/INCIDENT INVESTIGATIONS REGARDING DEGRADATION OF PILOT PERFORMANCE AS A RESULT OF AUTOMATION TO MODIFY PILOT TRAINING PROGRAMS AND FLIGHT PROCEDURES SO AS TO TAKE FULL ADVANTAGE OF THE SAFETY BENEFITS OF AUTOMATION TECHNOLOGY.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: JAMAICA, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA84AA018
Accident Reports: Scandinavian Airlines System Flight 901, McDonnell Douglas DC-10-30
Report #: AAR-84-15
Accident Date: 2/28/1984
Issue Date: 11/16/1984
Date Closed: 7/11/1991
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Flightcrew, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/11/1991
Response: Safety Recommendation A-84-123 states that the FAA should apply the findings of behavioral research programs and accident/incident investigations regarding degradation of pilot performance as a result of automation to modify pilot training programs and flight procedures so as to take full advantage of the safety benefits of automation technology. The Safety Board notes that on September 6, 1990, the FAA issued Advisory Circular (AC) 120-35B, Line Operational Simulations: Line-Oriented Flight Training, Special Purpose Operational Training, Line Operational Evaluation. This AC presents guidelines for the design and implementation of line operational simulations, includng line-oriented flight training, special purpose operational training, and line operational flight evaluation. The Safety Board also notes that on October 2, 1990, the FAA published an Advanced Qualification Program Special Federal Aviation Regulation (SFAR). This SFAR establishes an alternative method of traditional training programs and allows certificate holders that are subject to the training requirements of 14 CFR Parts 121 and 135 to develop innovative training programs that incorporate the most recent advances in training methods and techniques. Although the degradation of pilot performance as a result of automation is not directly addressed in the FAA response, the Safety Board believes that the FAA has addressed other broader issues of human performance that have been uncovered in the investigation of aviation accidents, particularly with its heavy emphasis on Cockpit Resource Management Training. Specifically, the Safety Board has monitored with interest the FAA's collaboration with NASA and aviation industry representatives in the development of a comprehensive "National Plan for Aviation Human Factors," in recent months. The Safety Board notes that several of the stated objectives of this plan bear directly on the intent of the recommendation. Based on a review of the plan, the Safety Board is satisfied that, if properly implemented and adequately supported, it will significantly alleviate many of the important human performance problems facing the aviation community. Based on the above information, Safety Recommendation A-84-123 is classified as "Closed--Acceptable Alternate Action."

From: FAA
To: NTSB
Date: 3/12/1991
Response: ON SEPTEMBER 6, 1990, THE FAA ISSUED AC 12O-35B, LINE OPERATIONAL SIMULATIONS: LINE-ORIENTED FLIGHT TRAINING, SPECIAL PURPOSE OPERATIONAL TRAINING, LINE OPERATIONAL EVALUATION. THIS AC PRESENTS GUIDELINES FOR THE DESIGN AND IMPLEMENTATION OF LINE OPERATIONAL SIMULATIONS, INCLUDING LINE-ORIENTED FLIGHT TRAINING, SPECIAL PURPOSE OPERATIONAL TRAINING, AND LINE OPERATIONAL FLIGHT EVALUATION. ON OCTOBER 2, 1990, THE FAA PUBLISHED AN ADVANCED QUALIFICATION PROGRAM SPECIAL FEDERAL AVIATION REGULATION (SFAR). THIS SFAR ESTABLISHERS AN ALTERNATIVE METHOD OF TRADITIONAL TRAINING PROGRAMS AND ALLOWS CERTIFICATE HOLDERS THAT ARE SUBJECT TO THE TRAINING REQUIREMENTS OF 14 CFR PARTS 121 AND 135 TO DEVELOP INNOVATIVE TRAINING PROGRAMS THAT INCORPORATE THE MOST RECENT ADVANCES IN TRAINING METHODS AND TECHNIQUES.

From: NTSB
To: FAA
Date: 11/21/1990
Response: Thank you for your August 31, 1990, letter in further response to Safety Recommendation A-84-123. The Safety Board is pleased to learn that the FAA is developing an advisory circular to provide guidelines for the design and implementation of line operational simulations, including line-oriented flight training, special purpose operational training, and line operational flight evaluation. We also note that the FAA is considering the issuance of an Advanced Qualification Program Special Federal Aviation Regulation proposing to provide an alternative to traditional training programs. We look forward to the FAA's further progress on this recommendation which is classified as "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 8/31/1990
Response: THE FAA IS DEVELOPING AN ADVISORY CIRCULAR TO PROVIDE GUIDELINES FOR THE DESIGN & IMPLEMENTATION OF LINE OPERATIONAL SIMULATIONS, INCLUDING LINE-ORIENTED FLIGHT TRAINING, SPECIAL PURPOSE OPERATIONAL TRAINING, & LINE OPERATIONAL FLIGHT EVALUATION. THE FAA IS CONSIDERING THE ISSUANCE OF AN ADVANCED QUALIFICATION PROGRAM SPECIAL FEDERAL AVIATION REGULATION (SFAR) PROPOSING TO PROVIDE AN ALTERNATIVE TO TRADITIONAL TRAINING PROGRAMS.

From: NTSB
To: FAA
Date: 2/21/1989
Response: Thank you for your further response to Safety Recommendation A-84-123. We are pleased to learn that the FAA is expediting the research to resolve human performance safety issues, and we appreciate receiving copies of the FAA's "Cockpit Human Factors Research Plan" and "National Plan to Enhance Aviation Safety Through Human Factors Improvements." We look forward to the FAA's progress on this recommendation which is classified as "Open--Acceptable Action."

From: FAA
To: NTSB
Date: 12/23/1988
Response: THE FAA IS EXPEDITING THE RESEARCH TO RESOLVE THE HUMAN PERFORMANCE SAFETY ISSUES. THE FAA HAS REQUESTED $25 MILLION FOR FISCAL YEAR 1990 TO BE USED SOLELY FOR HUMAN FACTORS RESEARCH PROJECTS AND ACTIVITIES. I WILL CONTINUE TO KEEP THE SAFETY BOARD APPRISED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 10/12/1988
Response: The Safety Board is aware of the FAA's ongoing program to address human performance. We encourage you to expedite your work with the aviation industry and the National Aeronautics and Space Administration to develop a national plan for human factors research. We note that the FAA responses of February 25, and June 10, 1985, both discussed "ongoing" aviation behavioral research projects. We look forward to some definition and application of these efforts in the very near future. Specifically, we would appreciate receiving a report of the progress of this program to date, including a copy of the national plan for human factors research, and any projected plans and target dates for implementation of research results. In the meantime, we will continue to hold Safety Recommendation A-84-123 in an "Open--Acceptable Action," status. We appreciate your commitment to keep the Safety Board apprised of the FAA's progress on this issue.

From: FAA
To: NTSB
Date: 2/22/1988
Response: THE FAA HAS AN ONGOING COMPREHENSIVE PROGRAM TO ADDRESS THIS SAFETY RECOMMENDATION. THE FAA IS CURRENTLY WORKING WITH THE AVIATION INDUSTRY AND NASA TO DEVELOP A NOTIONAL PLAN FOR HUMAN FACTORS RESEARCH. ONE KEY PROGRAM AREA DEALS WITH AUTOMATION AND THE EFFECT ON HUMAN PERFORMANCE, BOTH WITH THE COCKPIT CREW AND WITH AIR TRAFFIC. THE RESULTS OF THISP AND OPERATIONAL PROCEDURES.

From: NTSB
To: FAA
Date: 9/12/1985
Response: The Safety Board is pleased to learn that the FAA has identified several aviation behavioral research projects for funding. Additionally, we believe that the creation of a glossary of aviation human factors terms and the development of a human factors data base will help improve the understanding of the human input in aviation accidents. Since a final Aviation Behavioral Technology plan is expected shortly, Safety Recommendation A-84-123 has been classified as "Open--Acceptable Action" pending our review of the plan.

From: FAA
To: NTSB
Date: 6/10/1985
Response: FAA LTR: I WAS BRIEFED ON THE FEDERAL AVIATION ADMINISTRATION'S (FAA) AVIATION BEHAVIORAL TECHNOLOGY PLAN ON JANUARY 30, 1985. RESOURCES ARE NOW BEING IDENTIFIED TO INITIATE THE SELECTED PROJECTS. INCLUDED IN THE PLAN ARE A NUMBER OF ONGOING PROJECTS: PILOT JUDGMENT TRAINING, STUDY OF COLOR DEFICIENCY, CREW FATIGUE, SIMULATOR FIDELITY, AND VOICE SYSTEMS. IN ADDITION, A GLOSSARY OF AVIATION HUMAN FACTORS TERMS AND A HUMAN FACTORS DATA BASE ARE BEING DEVELOPED. THE FINALIZED PLAN WILL BE PUBLISHED BEFORE JULY 1, 1985. AT THAT TIME, WE WILL BE PREPARED TO BRIEF THE BOARD ON THE STATUS OF THE CURRENT PROJECTS AND FUTURE INITIATIVES.

From: NTSB
To: FAA
Date: 4/19/1985
Response: The Safety Board is pleased to learn that the FAA Office of Flight Operations has an ongoing Aviation Behavioral Technology Plan to develop and apply advanced behavioral analysis with regard to changing and developing aircraft technology. This plan complies with the intent of this Safety Recommendation; however, rather that close this recommendation the Safety Board prefers that it remain open so that developments in this evolving field can be monitored. The Safety Board requests that the FAA provide additional information on the current activities and findings of the Aviation Behavioral Technology Plan. Pending further review of pilot performance as a result of increased automation, Safety Recommendation A-84-123 has been classified as "Open--Acceptable Action."

From: FAA
To: NTSB
Date: 2/25/1985
Response: FAA LTR: THE FAA HAS AN ONGOING, COMPREHENSIVE PROGRAM TO ACCOMPLISH THE WORK IMPLICATED IN A-84-123. THIS PROGRAM IS DETAILED IN THE FAA'S AVIATION BEHAVIORAL TECHNOLOGY PLAN AND IS INTENDED TO DEVELOP AND APPLY ADVANCED BEHAVIORAL ANALYSIS AND TECHNOLOGY TO IMPROVE FLIGHT SAFETY AND PROMOTE CIVIL AVIATION. THE FOUR MAJOR AREAS IN THIS PLAN ARE: (1) TO DEVELOP CRITERIA FOR THE CERTIFICATION OF ADVANCED COCKPIT TECHNOLOGY; (2) TO IDENTIFY CAUSAL FACTORS OF PILOT ERROR; (3) TO ENHANCE CREW TRAINING AND; (4) TO UPDATE AND SIMPLIFY FEDERAL AVIATION REGULATIONS RELATING TO HUMAN PERFORMANCE. THE FAA'S OFFICE OF FLIGHT OPERATIONS WHICH HAS REGULATORY AUTHORITY IN THE OPERATIONAL AREAS ADDRESSED IN A-84-123, HAS MANAGEMENT RESPONSIBILITY FOR THE FAA'S AVIATION BEHAVIORAL TECHNOLOGY PLAN. THIS ENSURES THAT RESEARCH FINDINGS AND ACCIDENT ANALYSES REGARDING DEGRADING OF PILOT PERFORMANCE AS A RESULT OF AUTOMATION WILL BE APPROPRIATELY USED TO KEEP REGULATIONS AND REGULATORY GUIDANCE MATERIAL CURRENT WITH AUTOMATION TECHNOLOGY. CONSEQUENTLY, WE BELIEVE THAT THE INTENT OF A-84-123 IS SATISFIED BY OUR PROGRAM, AND WE PLAN NO ADDITIONAL ACTION ON THIS RECOMMENDATION.